Documentation Defined

For the purpose of this PPG, the term ‘Personal Health Record’ or ‘PHR’ refers to the record of clinical care provided to the patient/client, including (but not limited to):

The CRTO’s Standard of Practice, which outlines the expectation of RTs when documenting states that:

“Patients/clients can expect that RTs keep complete, clear, timely, objective, and accurate records of the care provided and that privacy/confidentiality is protected.”

This Documentation PPG is intended to provide Members with information on the CRTO’s expectations related to documentation. The CRTO has also developed several other relevant PPGs that may have complementary and overlapping information related to documentation, such as:

RTs may select any style of charting that fits with their practice, provided that it adheres to both the standards, expectations and requirements of both the CRTO and the employer.

Examples of different charting styles are:

Documentation is effective when it enables members of a patient/client’s health care team to have access to the information needed to deliver optimal patient/client care (for both present and future needs). Regardless of the practice setting (ICU, home care, emergency, outpatient clinic, primary care, operating room (OR), diagnostics, research), the principles of PHR documentation are the same. The CRTO acknowledges the difficulties often associated with documenting in areas such as the OR, emergency, home care and patient transport. However, we encourage all CRTO Members to work with their employer to find solutions to these challenges.

Effective documentation forms the basis of any PHR and must be:

For example… If three (3) attempts are required to successfully intubate a patient, then all three (3) attempts should be documented.

The professional standard of practice is that every contact between an RT and a patient/client must be documented. A patient/client contact can include contact for the purposes of:

For example…Conferring with other members of the health care team (including the patient/client’s family members) regarding their orders or medical status is also considered to be a patient/client contact.

It is important to note that patient/client contact includes not only direct patient/client care, but also indirect contact regarding a specific patient/client, such as communication via:

* For information on the use social media in professional practice, please view the Use of Social Media by Respiratory Therapists Fact Sheet

All RTs must respect and protect patient/client confidentiality and privacy in every aspect of their practice. RTs can only share patient/client information with the consent of the patient/client, or as required where permitted by law. Personal health information should only be shared within the “circle of care” in the following circumstances:

PHIPA provides specific guidance for handling the collection, use and disclosure of personal health information by information custodians. RTs who are employees of hospitals, or most other facilities, are not custodians but “agents” of organizational custodian. Therefore, it is the organizational custodian (employer) who is responsible for developing policies and procedures for the collection, use, disclosure and protection of personal health information under PHIPA, and for ensuring compliance. As an agent, the RT must comply with the custodian’s privacy practices when acting on the custodian’s behalf, unless otherwise permitted by law.

It is the organizational custodian (employer) who is responsible for developing policies and procedures for the collection, use, disclosure and protection of personal health information under PHIPA, and for ensuring compliance. As an agent, the RT must comply with the custodian’s privacy practices when acting on the custodian’s behalf, unless otherwise permitted by law.

RTs who are self-employed or are employed by others who are not health information custodians (e.g., an insurance company, a school board, industry) are considered to be health information custodians, and therefore responsible for developing a privacy policy and ensuring compliance with PHIPA.

Members are reminded that confidentiality is not limited to sharing of health records with others, and should consider other potential breaches, such as:

While less secure and reliable, many healthcare organizations continue to rely on fax machines for the transmission of patient information. Members should take extra care when faxing and receiving faxes containing personal health and other confidential information by ensuring: